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KIRUB KIRUB 2008 2008
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KIRUBKIRUB
20082008
EDTEDTEmergency Department ThoracotomyEmergency Department Thoracotomy
Thoracic traumaThoracic trauma
Katastrofmedicinsk CentrumKatastrofmedicinsk Centrum
UniversitetssjukhusetUniversitetssjukhuset
LinköpingLinköping
Tore VikströmTore Vikström
Theodore Billroth 1883Theodore Billroth 1883
”The Surgeon who should attempt to suture a wound of the heart would lose the respect of his colleagues”
Life-threatening Thoracic Life-threatening Thoracic traumatrauma
(Airway obstruction)(Airway obstruction)
Tension pneumothoraxTension pneumothorax
Open pneumothoraxOpen pneumothorax
Flail chestFlail chest
Massive hemothoraxMassive hemothorax
Cardiac tamponadeCardiac tamponade
EDTEDT
Emergency – Hurry – Go ahead – Hurray !Emergency – Hurry – Go ahead – Hurray !
Finnish at the ORFinnish at the OR
Thoracic traumaThoracic trauma
25-50% of deaths 25-50% of deaths
Penetrating Penetrating < 30% require operation< 30% require operation
Blunt Blunt <10% require operation<10% require operation
Majority: simple proceduresMajority: simple proceduresHunt PA, Greaves I, Owens WA.Department of Academic Emergency Medicine, James Cook University Hospital, Marton Road, Middlesbrough, Cleveland TS4 3BW, UKDepartment of Academic Emergency Medicine, James Cook University Hospital, Marton Road, Middlesbrough, Cleveland TS4 3BW, UK Thoracic Trauma and Critical Care (textbook)Thoracic Trauma and Critical Care (textbook)
EDTEDT
IndicationsIndications
Penetrating thoracic injuryPenetrating thoracic injury
PEAPEA
ContraindicationsContraindications
Blunt trauma in multitraumaBlunt trauma in multitrauma
Corsi PR, Prado Pde A, Rasslan S. Department of Surgery, Faculdade de Ciencias Medicas da Santa Casa de Sao Paulo, Brazil.Thoracic Trauma and Critical Care (textbook)Thoracic Trauma and Critical Care (textbook)
Who benefits from EDT ?Who benefits from EDT ?
””The value of EDT in resuscitation of The value of EDT in resuscitation of the patient in profound shock but not the patient in profound shock but not yet dead is unquestionable”yet dead is unquestionable”
Cothren CC, Moore EE. Department of Surgery, Denver Health Medical Center and the University of Colorado Health Sciences Center, Denver, CO, USA. [email protected]. World J Emerg Surg. 2006 Mar 24;1:4 Sheppard FR, Cothren CC, Moore EE, Orfanakis A, Ciesla DJ, Johnson JL, Burch JM. Department of Surgery, Denver Health Medical Center, Denver, CO 80204, USA. 1: Surgery. 2006 Apr;139(4):574-6.
Who benefits from EDT ?Who benefits from EDT ?
That is: ”half dead” and ”new dead”
Cothren CC, Moore EE. Department of Surgery, Denver Health Medical Center and the University of Colorado Health Sciences Center, Denver, CO, USA. [email protected]. World J Emerg Surg. 2006 Mar 24;1:4 Sheppard FR, Cothren CC, Moore EE, Orfanakis A, Ciesla DJ, Johnson JL, Burch JM. Department of Surgery, Denver Health Medical Center, Denver, CO 80204, USA. 1: Surgery. 2006 Apr;139(4):574-6.
EDTEDT
Survival rates P/B (n=4 620)Survival rates P/B (n=4 620)
Overall: 7,4% (range 1,8%-27,5%)Overall: 7,4% (range 1,8%-27,5%)
MOI: 8,8% P 1,8% BMOI: 8,8% P 1,8% B
Stab: 16,8%Stab: 16,8%Gunshot: 4,3%Gunshot: 4,3%Normal neurology: 92,4%Normal neurology: 92,4%
Peter M Rhee J Am Coll Surg;2000Peter M Rhee J Am Coll Surg;2000
Survival rate correlates Survival rate correlates to:to:
Signs Of Life (SOL) (SOL) Cardiac electrical activity Cardiac electrical activity Respiratory effort Respiratory effort Pupillary response Pupillary response
Mechanism Of Injury (MOI)Mechanism Of Injury (MOI)
Location Of Major Injury (LOMI)Location Of Major Injury (LOMI)
MOIMOI
LOMILOMI• MultitraumaMultitrauma 0.7%0.7%• BukBuk 4.5%4.5%• Thorax Thorax 10.7%10.7%• Hjärta Hjärta 19.4%19.4%
• Trubbigt våld Trubbigt våld 1.4%1.4%• SkottskadaSkottskada 4.3%4.3%• StickskadaStickskada 16.8%16.8%
SOLSOL• Saknas på skadeplatsSaknas på skadeplats 1.2%1.2%• Finns under transport Finns under transport 8.9%8.9%• Saknas vid ankomst till sjukhus Saknas vid ankomst till sjukhus 2.6%2.6%• Finns vid ankomst till sjukhusFinns vid ankomst till sjukhus 11.5%11.5%
Best survival ratesBest survival ratesEDT for stab injuries who arrive with EDT for stab injuries who arrive with SOLSOL
Low survival ratesLow survival ratesBlunt trauma/multitraumaBlunt trauma/multitrauma
No No SOLSOL in the field in the field
Time is of essenseTime is of essense
Scoop and run ! Scoop and run !
≤≤ 10 min av CPR10 min av CPR
VOMITVOMIT
VVictimictim OOff MModernodern IImaginmaginTTechnologyechnology
Choose the right trackChoose the right track
ATLSATLS
• AAirwayirway
• BBreathingreathing
• CCirculationirculation
• DDisabilityisability
• EExposurexposure
””CTLS”CTLS”
• AAirwayirway
• BBreathingreathing
• CCT scanT scan
• DDeatheath
• EEternityternity
PitfallsPitfalls
DelayDelay
Too small incisionToo small incision
Peroperative heart injuryPeroperative heart injury
Suture over coronary arterySuture over coronary artery
Peroperative lung injuryPeroperative lung injury
Peroperative oesophagus injuryPeroperative oesophagus injury
Indication ?Indication ?
……...in the ED...in the ED
Thoracotomi equipmentThoracotomi equipment
Prepared personellPrepared personell
Resuscitation areaResuscitation area
Summary EDTSummary EDT
IndicationsIndications – Stab woundsStab wounds– Deep shock (BP<70 mmHg)Deep shock (BP<70 mmHg)– Non responderNon responder– Cardiac arrest in the EDCardiac arrest in the ED– ≤≤ 10 min CPR10 min CPR
Emergency procedure – now !Emergency procedure – now !
1 out of 4 can be saved1 out of 4 can be saved
EDT is part of damage control EDT is part of damage control
ReferencesReferencesHunt PAHunt PA, , Greaves IGreaves I, , Owens WAOwens WA.Department of Academic Emergency Medicine, James Cook University Hospital, Marton Road, Middlesbrough, .Department of Academic Emergency Medicine, James Cook University Hospital, Marton Road, Middlesbrough, Cleveland TS4 3BW, UK. [email protected] TS4 3BW, UK. [email protected] Emergency thoracotomy in thoracic trauma-a Emergency thoracotomy in thoracic trauma-a
[[Kiss LKiss L, , LapadatuLapadatu E E, , BalintBalint I I. Sectia chirurgie de urgenta, Spitalul Municipal Petrosani.. Sectia chirurgie de urgenta, Spitalul Municipal Petrosani.
The incidence of emergency thoracotomy in thoracic trauma. 7000 cases of thoracic trauma (T.T.) treated in the period of 1978-The incidence of emergency thoracotomy in thoracic trauma. 7000 cases of thoracic trauma (T.T.) treated in the period of 1978-
1995]1995]
Grove CAGrove CA, , Lemmon GLemmon G, , Anderson GAnderson G, , McCarthy MMcCarthy M Emergency thoracotomy: appropriate use in the resuscitation of trauma patients.Emergency thoracotomy: appropriate use in the resuscitation of trauma patients.
Am Surg. 2002 Apr;68(4):313-6; discussion 316-7. Am Surg. 2002 Apr;68(4):313-6; discussion 316-7.
JahangiriJahangiri M M, , Hyde JHyde J, , Griffin SGriffin S, , Magee PMagee P, , YouhanaYouhana A A, , Lewis TLewis T, , Wood AWood A..Emergency thoracotomy for thoracic trauma in the accident and emergency department: indications and outcome.Emergency thoracotomy for thoracic trauma in the accident and emergency department: indications and outcome. Ann R Coll Surg Engl. 1996 May;78(3 ( Pt 1)):221-4Ann R Coll Surg Engl. 1996 May;78(3 ( Pt 1)):221-4 MansourMansour MA MA, , Moore EEMoore EE, , Moore FAMoore FA, , Read RRRead RR..Exigent postinjury thoracotomy analysis of blunt versus penetrating trauma. Surg Gynecol Obstet. 1992 Exigent postinjury thoracotomy analysis of blunt versus penetrating trauma. Surg Gynecol Obstet. 1992 Aug;175(2):97-101Aug;175(2):97-101 Washington BWashington B, , Wilson RFWilson RF, , SteigerSteiger Z Z, , Bassett JSBassett JS.Ann Thorac Surg. 1985 Aug;40(2):188-91. .Ann Thorac Surg. 1985 Aug;40(2):188-91. Emergency thoracotomy: a four-year review.Emergency thoracotomy: a four-year review. FrezzaFrezza EE EE, , MezghebeMezghebe H H. J Cardiovasc Surg (Torino). 1999 Feb;40(1):147-51. . J Cardiovasc Surg (Torino). 1999 Feb;40(1):147-51.
BodaiBodai BI BI, , Smith JPSmith JP, , WardWard RE RE, , O'Neill MBO'Neill MB, , AuborgAuborg R R. . JAMA. 1983 Apr 8;249(14):1891-6. JAMA. 1983 Apr 8;249(14):1891-6.
Emergency thoracotomy in the management of trauma.Emergency thoracotomy in the management of trauma.MazzoranaMazzorana V V, , Smith RSSmith RS, , MorabitoMorabito DJ DJ, , BrarBrar HS HS.. Am Surg. 1994 Jul;60(7):516-20; discussion 520-1. Am Surg. 1994 Jul;60(7):516-20; discussion 520-1. Brown SEBrown SE, , Gomez GAGomez GA, , Jacobson LEJacobson LE, , Scherer T 3rdScherer T 3rd, , McMillan RAMcMillan RA Am Surg. 1996 Jul;62(7):530-3; discussion 533-4. Am Surg. 1996 Jul;62(7):530-3; discussion 533-4.
Penetrating chest trauma: should indications for emergency room thoracotomy be limitedPenetrating chest trauma: should indications for emergency room thoracotomy be limited BodaiBodai BI BI, , Smith JPSmith JP, , BlaisdellBlaisdell FW FW.. J Trauma. 1982 Jun;22(6):487-91 J Trauma. 1982 Jun;22(6):487-91 The role of emergency thoracotomy in blunt trauma.The role of emergency thoracotomy in blunt trauma. Lorenz HPLorenz HP, , Steinmetz BSteinmetz B, , LiebermanLieberman J J, , SchecoterSchecoter WP WP, , Macho JRMacho JR.. J Trauma. 1992 Jun;32(6):780-5; discussion 785-8. J Trauma. 1992 Jun;32(6):780-5; discussion 785-8. Emergency Emergency thoracotomy: survival correlates with physiologic status.thoracotomy: survival correlates with physiologic status. BeltramiBeltrami V V, , BertagniBertagni A A, , GallinaroGallinaro L L, , Montesano GMontesano G, , PrecePrece V V.. Ann Ital Chir. 2000 Jul-Aug;71(4):425-30.Ann Ital Chir. 2000 Jul-Aug;71(4):425-30. Major surgery in thoracic injuries.Major surgery in thoracic injuries.Karmy-JonesKarmy-Jones R R, , NathensNathens A A, , JurkovichJurkovich GJ GJ, , ShatzShatz DV DV, , Brundage SBrundage S, , Wall MJ JrWall MJ Jr, , EngelhardtEngelhardt S S, , HoytHoyt DB DB, , HolcroftHolcroft J J, , KnudsonKnudson MM MM, , Michaels AMichaels A, , Long WLong W..J Trauma. 2004 Mar;56(3):664-8; discussion 668-9. J Trauma. 2004 Mar;56(3):664-8; discussion 668-9. Urgent and emergent thoracotomy for penetrating chest trauma.Urgent and emergent thoracotomy for penetrating chest trauma. Lewis GLewis G, , KnottenbeltKnottenbelt JD JD Injury. 1991 Jan;22(1):5-6. Injury. 1991 Jan;22(1):5-6. Should emergency room thoracotomy be reserved for cases of cardiac tamponade?Should emergency room thoracotomy be reserved for cases of cardiac tamponade? FialkaFialka C C, , SebokSebok C C, , KemetzhoferKemetzhofer P P, , KwasnyKwasny O O, , SterzSterz F F, , VecseiVecsei V V. . J Trauma. 2004 Oct;57(4):809-14 J Trauma. 2004 Oct;57(4):809-14 Open-chest cardiopulmonary resuscitation after cardiac arrest in cases of blunt chest or abdominal Open-chest cardiopulmonary resuscitation after cardiac arrest in cases of blunt chest or abdominal trauma: a consecutive series of 38 cases.trauma: a consecutive series of 38 cases. von von OppellOppell UO UO, , BautzBautz P P, , De De GrootGroot M M.. Thorac Cardiovasc Surg. 2000 Feb;48(1):55-61. Thorac Cardiovasc Surg. 2000 Feb;48(1):55-61. Penetrating thoracic injuries: what we have learnt.Penetrating thoracic injuries: what we have learnt.
